| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D2930 |
Prefabricated stainless steel crown - primary tooth |
1,098 |
236 |
$113K |
| D3220 |
Therapeutic pulpotomy (excluding final restoration) - removal of pulp coronal to the dentinocemental junction |
1,283 |
258 |
$83K |
| D1120 |
Prophylaxis - child |
2,914 |
2,826 |
$56K |
| D1208 |
Topical application of fluoride, excluding varnish |
3,262 |
3,153 |
$48K |
| D0120 |
Periodic oral evaluation - established patient |
2,273 |
2,190 |
$37K |
| D1351 |
Sealant - per tooth |
1,615 |
409 |
$35K |
| D7140 |
Extraction, erupted tooth or exposed root |
396 |
137 |
$23K |
| D0272 |
Bitewings - two radiographic images |
1,881 |
1,818 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
689 |
671 |
$18K |
| D1110 |
Prophylaxis - adult |
558 |
532 |
$18K |
| D0240 |
|
501 |
264 |
$5K |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
90 |
55 |
$5K |
| D1206 |
Topical application of fluoride varnish |
217 |
214 |
$3K |
| D0330 |
Panoramic radiographic image |
70 |
66 |
$3K |